CONTACT:
EXAM REQUEST

REQUEST AN EVALUATION

Please use the following form to request an evaluation. This form may be used for an Independent Medical Evaluation (IME), Qualified Medical Evaluation (QME) or an Agreed Medical Evaluation (AME), anywhere within the United States and Canada.

    Type*

    Speciality

    Transportation needed?

    Interpreter Needed?

    CLAIMANT INFORMATION

    Claim Number

    Claimant Name

    Claimant Address

    Address Line 2

    City / State / ZIP

    Country

    Phone / Mobile #

    Date of Birth

    EMPLOYER INFORMATION

    Employer

    Date of Injury

    Job Title

    INSURANCE INFORMATION

    Insurance Company

    Address

    Address Line 2

    City / State / ZIP

    Country

    CLAIMS EXAMINER

    Examiner Name

    Examiner Phone

    Examiner Fax

    Email Address

    Special Instructions/
    Requests

    Data will be transmitted to our server over a secure HTTPS connection using TLS 1.2 and SHA-256 encryption when this form is submitted. Once you press submit, you will receive an e-mail confirmation from Prime Medical Evaluators coordinator within 30 minutes.